In today's healthcare delivery model, an industry gap exists between payers, the organizers of benefit and payment systems, providers, responsible for the hands on delivery of care, and patients. Although certain aspects of the healthcare delivery model have been improved, further improvements are needed in the areas of electronic exchange of eligibility, claims submissions, claims status inquiries, and payment remittance. Further new technology systems providing efficient, systematic, and streamlined processes that provide a foundation for emerging business and technology trends must be further developed.
The industry has focused on processing pre-care eligibility inquiries from health care providers, post-care claims submissions, inquiries, responses, and financial transactions such as claim submission and tracking, payment remittance advices, and patient statements. Real time transaction processing is supported for only certain processes such as eligibility inquiries, for example. A need for additional real time transaction processing in the areas of payment assurance, referrals, patient health care itineraries, and care management between payers and providers is needed. Presently, most transactions between providers, clearinghouses, and payers are conducted via batch processing systems, resulting in responses to providers often measured in days.
In this context, there is a need for new systems providing efficient, real time, streamlined processes in connection with payment assurance and claim pre-validation in the healthcare field.